19 January 2010

I recently was served notice that I have "made it" as a blogger -- power, influence, prestige, all the perks of fame. Which is to say that I was sent a review copy of a book I probably would have bought anyway. I mean, it doesn't get much better than that, does it? A free book!

Well.

Here's my bottom line: if I had paid good money of my own, money that could have been spent instead on ice cream or video games, I would consider it money well spent. You can't ask for better than that, right?

Oh yeah, I should probably tell you a little more, like the title of the book. I kinda feel like I owe the PR guy who sent me the copy that much at least. It was Atul Gawande's The Checklist Manifesto (available at Amazon.com for $10.00 with FREE Super Saver Shipping).

He has it named right: it's a manifesto, in the old sense -- it's a public declaration of a belief or creed. By which I mean Gawande has hit upon a good idea -- a very powerful idea with a lot of potential -- and he's not going to let it go. He worries at it like a dog at a bone, only with more evangelical fervor, and he's bound and determined to see it adopted as widely as possible.

It all began with his landmark article in the New Yorker, two years ago, called, more simply, The Checklist. Indeed the first couple of chapters of the book amount in large part to a reprint of the New Yorker article. I would have felt ripped off if it didn't go beyond that, but it does, fortunately. And the ultimate test of a good book -- it made me re-evaluate and change my thinking.

From my point of view, checklists in medicine seemed like a nifty idea -- for someone else. For surgeons and ICU doctors, they have good applicability, I thought. Those doctors are doing the same thing over and over again. Those doctors are vulnerable to the fatigue of routine and forgetting to do the simple obligate items, and a checklist can really help them. Central line? Good -- do a checklist. Ventilator patient? Good -- checklist. We're not like that in the ER. We don't do the same things over and over again -- we have too much variability from day to day and patient to patient. Our job is too different and unpredictable for checklists to play any role, right?

Maybe not.

Sure, in the ER there are lots of different patient types. There are the chest pains, the belly pains, the migraneurs, the minor traumas, the weak&dizzies, etc. But that applies to the OR as well, doesn't it? The checklists are not there to tell the surgeon how to resect the duodenum, and checklists for the ER would not tell me how to evaluate a patient with chest pain. Checklists are not for higher-level decision-making. They're for, as Gawande put it, "the stupid stuff." When Captain "Sully" Sullenberger decided to ditch his plane in the Hudson River, the checklists did not tell him how to pick the landing site or gently kiss the plane onto the river's surface. But the checklists did allow his co-pilot second officer to run restarts on both engines prior to ditching and reminded him to close the hatches without which the aircraft might have quickly sunk.

In "Checklist Manifesto," Gawande extends the concept from the ICU to the OR, as published in the NEJM [PDF] article about the surgical safety checklist which produced such seemingly improbable reductions in morbidity and mortality, and to more chaotic endeavors such as the erection of large buildings. What struck me were how simple and obvious many of the critical items were, and how well some translate to the ER.

For example: before the operation, very person in the room must introduce him or herself and state their role in the case (thankfully, this is done after the patient is asleep), and is given the opportunity to voice any thoughts or concerns they may have. What a simple and effective tool! I think of the ER, where we have 300 nurses, including part-timers and floaters, and how often it is that a nurse does not know me, or I do not know the names of the nurses, and how often that leads to a failure to communicate. Gawande admitted that this was one of the harder steps to actually adopt, and I sympathize. Last year, we tried "shift huddles" in the ER for the same purpose. It was a failure and quickly dropped by most providers, primarily because it felt silly and awkward. Now that I think about it some more, I think I will see if we can re-initiate these huddles. If they caught on, they could be very valuable.

When I initiated a discussion about checklists in the ER among our docs, there was widespread skepticism. Of course, I had top point out, we do already have and use a multitude of checklists, we just don't call them checklists. We call them protocols, or standing orders. Just like the USAir Airbus has checklists for "engine failure/restart" and "ditching," we have our checklists for "sepsis" or "Acute MI." Just as the checklists for aviation remind you of the critical actions, so the protocols make sure the simple but important items are not omitted. I recently had an MI patient who walked in who I nearly forgot to give an aspirin to! It's the most basic and hugely effective intervention for patients with heart attacks, but it's also usually done by the paramedics before the patient arrives. This got missed because this patient did not come in by ambulance. Fortunately, the checklist standing orders caught the omission. Similarly, when you have a shocky, hypotensive patient with sepsis, the tendency is to immediately put them on vasopressors to "fix" the blood pressure. By leaping straight for the pressors, you can forget to adequately hydrate them with a full 3L of saline, which will make the pressors more effective and in some cases may obviate them entirely.

These are simple, stupid interventions that are absolutely critical, as critical as remembering to close the hatches on ditching, and as easy to overlook. Just as the typical airline pilot has a sheaf of emergency procedures for every conceivable circumstance, so do we have reams of protocol order sets for most every common serious illness: DKA, CHF, MI, Sepsis, bronchiolitis, hip fractures, community-acquired pneumonia, etc.

I am wondering whether there are more concrete, global ways that checklists could be helpful in the ER, along the lines of the shift huddles. That will take some creative thinking.

Coming back to Gawande's book: it's more than worth the read. It's a great primer for anybody who is interested in organizational quality and patient safety. It also is very readable, with lots of patient stories and other anecdotes that ground the theory in real-world experience.

I'm still a medical student but I can definitely see the values in checklists. A practical way to perform the checklists is to integrate them into mobile devices. With the available technology checklists can quickly and easily be made available for numerous conditions/situations. Further, algorithms for common presentations can be preset such as "chest pain" to make sure the "stupid stuff" is never forgotten. I can't wait to read the book (after I'm done with Step 1 of course).

I have found checklists to be valuable in all areas of my life. Like you said, they are good for remembering the stupid, little stuff that's easy to forget. I have seen several articles lately about using checklists in medicine and I think it's worth taking a look. Especially with the litigious society we live in, checklists might help ensure you dot the i's and cross the t's.

In the aircraft, important items are committed to memory. After those items are completed, THEN you pull out the checklist and work through the smaller stuff.

Sorry, I can't help myself but I have to point out that the co-pilot is the First Officer, not the second officer. Back when planes, such as the 727 had three pilots, the Flight Engineer was the Second Officer.

Minor correction: Sullenberger never even got to the point in the checklist where they would have activated the ditching switch.

The point remains the same, though. They didn't get that far because they were following the higher-priority checklist for the engine failure.

See: http://www.airspacemag.com/flight-today/Sullys-Tale.html

Air & Space: So your first officer would have found that procedure and had a checklist to go through for the ditching procedure?

Sullenberger: Not in this case. Time would not allow it. The higher priority procedure to follow was for the loss of both engines. The ditching would have been far secondary to that. Not only did we not have time to go through a ditching checklist, we didn’t have time to even finish the checklist for loss of thrust in both engines. That was a three-page checklist, and we didn’t even have time to finish the first page. That’s how time-compressed this was.

Air & Space: Did the airplane have a ditch button that would have sealed certain openings in the cabin?

Sullenberger: Yes, it’s called a ditching push button. And there was not time. We never got to the ditching push button on the checklist. It wouldn’t have mattered anyway. The vents that are normally open are small. And once the airplane touched the water, the contact opened holes in the bottom of the airplane much, much larger than all of the vents that this ditching push button was designed to close.

I cannot conceive of any ditching or water landing where it would help. Theoretically I understand why the engineers included it. It sounded like a good idea, but not in practice. We had a successful water landing, and even then, from seeing pictures of [the airplane] being removed from the river by a crane, there were much larger holes than the vents this button was designed to close.

I see checklist medicine as great for use after you have your diagnosis but not for getting your diagnosis. We use one for sepsis and one for MI. The sepsis protocol ensures that we don't dilly dally around too long waiting for the BP to come up before we start the fluid resucitation. The MI so we remember the ASA, the heparin etc. Also they help with all the documentation.

The checklists have to be reserved for the cases where there is evidence to prove that certain actions have better outcomes. Then they're justified.

I think where they cause problems is when you try to diagnose with checklists. Lord save us from a "chest pain" checklist.

Shadowfax

About me: I am an ER physician and administrator living in the Pacific Northwest. I live with my wife and four kids. Various other interests include Shorin-ryu karate, general aviation, Irish music, Apple computers, and progressive politics. My kids do their best to ensure that I have little time to pursue these hobbies.

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